What is recommended to increase platelet count?

Recommendations for Increasing Platelet Count

For patients with low platelet counts, first-line treatment options include corticosteroids (prednisone or dexamethasone), intravenous immunoglobulin (IVIg), or anti-D immunoglobulin, with the choice depending on the severity of thrombocytopenia, presence of bleeding, and patient characteristics. 1

First-Line Treatment Options

Corticosteroids

• Prednisone at 1-2 mg/kg/day is effective for initial treatment of immune thrombocytopenia (ITP) 1
• High-dose dexamethasone (4 mg/kg/day for 3-4 days) can achieve response in 72-88% of patients within 72 hours 1
• Longer courses of corticosteroids are generally preferred over shorter courses for adults 1
• Dexamethasone may work faster than prednisone in increasing platelet counts and may have fewer adverse events due to shorter treatment duration 2

Intravenous Immunoglobulin (IVIg)

• IVIg raises platelet count in more than 80% of patients and works more rapidly than corticosteroids 1
• Recommended dose is 0.8-1 g/kg as a single dose, which may be repeated based on response 1
• Should be considered when a more rapid increase in platelet count is required 1
• Can be used with corticosteroids for faster platelet count increase 1

Anti-D Immunoglobulin

• Can be given to Rh(D)-positive, non-splenectomized patients as a short infusion 1
• Not advised in patients with decreased hemoglobin due to bleeding or with evidence of autoimmune hemolysis 1

Second-Line Treatment Options

Thrombopoietin Receptor Agonists

• Romiplostim is indicated for adult ITP patients who have had insufficient response to corticosteroids, immunoglobulins, or splenectomy 3
• Initial dose is 1 mcg/kg subcutaneously weekly, with adjustments based on platelet count response 3
• Target platelet count is ≥50 × 10^9/L to reduce bleeding risk 3
• Most adult patients respond to a median dose of 2-3 mcg/kg 3

Rituximab

• Should be considered for patients with significant ongoing bleeding despite first-line treatments 1
• May be considered as an alternative to splenectomy 1
• Combination of dexamethasone with rituximab in first-line treatment may produce higher response rates with better long-term results 2

Splenectomy

• Recommended for patients who have failed corticosteroid therapy 1
• Both laparoscopic and open splenectomy offer similar efficacy 1
• Should be delayed for at least 12 months in children unless accompanied by severe disease 1

Emergency Treatment for Severe Thrombocytopenia with Bleeding

• For life-threatening bleeding, use high-dose corticosteroids together with IVIg or IV anti-D 1
• Platelet transfusions may be considered in emergency situations 1
• Prophylactic platelet transfusion is recommended when counts are <10,000/mm³ in the absence of bleeding 1
• Higher platelet counts (≥50,000/mm³) are advised for active bleeding, surgery, or invasive procedures 1

Special Considerations

Secondary ITP

• For HCV-associated ITP, consider antiviral therapy if not contraindicated 1
• For HIV-associated ITP, effective viral suppression using antiretroviral therapy can improve thrombocytopenia 1

Pregnancy

• Pregnant patients requiring treatment should receive either corticosteroids or IVIg 1
• Mode of delivery should be based on obstetric indications rather than platelet count 1

Monitoring Recommendations

• Obtain complete blood counts weekly during dose adjustment phase of therapy 3
• After establishing a stable dose, monitor platelet counts monthly 3
• Continue monitoring weekly for at least 2 weeks following discontinuation of treatment 3

Pitfalls and Caveats

• Avoid prolonged corticosteroid treatment, especially in children, due to serious side effects 1
• Romiplostim should not be used to normalize platelet counts but rather to achieve a count sufficient to reduce bleeding risk 3
• Discontinue romiplostim if platelet count does not increase to a level sufficient to avoid clinically important bleeding after 4 weeks at maximum dose 3
• Anti-D immunoglobulin can cause mild extravascular hemolysis and rarely intravascular hemolysis, disseminated intravascular coagulation, and renal failure 1